Introduction
What Is the Cervix?
What Should I Know About HPV Infection?
Finding Abnormal Cells
What Do My Pap Test Results Mean?
Questions To Ask Your Health Care Provider
Finding the Support You Need
Table 1: What Your Pap Test/HPV Test Results Mean and Follow-Up
Table 2: Tests or Follow-Up Treatments That Health Care Providers Use for Abnormal Pap Tests
Table 3: What Does It Mean: Results From Your Biopsy or Endocervical Curettage
Table 4: Treatments for Major Cell Changes
Resources
Introduction
A Pap Test Showed Cell Changes in Your Cervix
You're probably reading this booklet because your health care
provider told you that your recent
Pap test
(sometimes called a
Pap smear) showed
cell
changes in your
cervix. Although it is
quite common to feel uneasy about your Pap test results, it may
comfort you to know that each year more than 3 million women
receive similar results.
|
"I didn't understand my results at first--
and a part of me didn't want to
understand. But I knew this was
important . . . and in the end,
everything turned out fine."
MARLENE, AGE 45
|
Not All Cell Changes Are Cancer
The good news is that almost always, women with cell changes do
not have
cancer
of the cervix (also called cervical cancer). But it is
important that you protect your health by getting the follow-up
tests and care that your health care provider suggests.
Cell changes do not mean that you will get cancer of the cervix.
And because your cell changes were found, simple tests or
treatments can help you. When cell changes are found and treated
early, almost all women can avoid getting cervical cancer.
Getting Your Questions Answered
So what is the next step? What do your results mean? Does this
mean you need treatment and, if so, what kind? This booklet helps
answer these questions and discusses:
- Types of changes in your cervix
- Common tests and treatments
- How to find the support and resources you need
You will probably have other questions, or you might be
concerned about the choices you may need to make. These
reactions are normal. But understanding your Pap test results--and
what to expect when the results are not normal--can help you
make informed decisions and plan your next steps.
A dictionary explains terms that may be
new to you. These terms will appear in bold.
What Is the Cervix?
The cervix is the narrow, lower part of the
uterus
(where the baby
grows when a woman is pregnant). During a
pelvic exam, the
doctor or nurse practitioner can see the cervix at the upper end of
the
vagina.
The cervix has an opening to the
endocervical canal. This
opening lets blood flow from the uterus into the vagina during a
woman's menstrual period. During childbirth, the cervix opens
much wider to let the baby pass through.
The surface lining of the cervix is made up of two different types
of cells:
- Tall cells, called
glandular cells (or columnar cells)
toward the top of
the endocervical
canal (above the
cervix). They make
mucus, which
helps guard the
entrance to the
uterus.
- Thin, flat cells,
called
squamous epithelial cells
(or squamous cells).
Arranged in layers,
they protect the
tissues underneath them.
Pap tests can help health care providers find changes in these cells.
|
|
|
Normal cervical cells |
Normal and
precancerous mix |
Precancerous
cervical cells |
Cervical cells can go through many types of changes that are not
cancer. Many times these changes will go away on their own.
These changes can be caused by:
These cell changes are very common and are not related to cancer.
But they sometimes make these cells look like
abnormal
cells. So
your health care provider may suggest that you repeat your
Pap test or have other follow-up tests to be certain you don't
have any cell changes. (See the tables beginning at Table 1 1 for
more information.)
Although most cell changes in the cervix are not cancer,
it is still important to get a Pap test at least once every
3 years to be sure.
|
Some cell changes are a sign of a certain viral infection called
HPV (human papillomavirus). In most women, HPV infections go
away on their own. Sometimes, the cells infected with HPV will
become
precancerous. These precancerous cells can become
cervical cancer (called
invasive cancer of the cervix). They can
grow and spread, invading nearby tissues and possibly spreading
throughout the body. An
HPV test,
which is done much like a
Pap test, can detect the virus in cervical cells.
What is HPV? |
- It is a very common virus.
- There are more than 100 types.
- About 15 types can cause cervical cancer.
- Some types cause warts on the fingers or feet but do not cause
cancer.
- Other types cause warts in the genital area that are not cancerous.
|
HPV is the most important cause of and
risk factor
for cervical
cancer. But studies have shown that other factors may act together
with HPV to increase your risk of developing cervical cancer. These
factors include cigarette smoking and having given birth to many
children. Also, if you have a weak immune system, you may be at
higher risk because your body may not be able to clear up HPV on
its own. For example, if you take medicine to block your body's
immune response or if you have
HIV, you may be at higher risk.
What Should I Know About HPV Infection?
Almost all HPV that affects the cervix is spread by sex
(through intimate
genital
to genital contact including vaginal or
anal intercourse, finger to genital contact, and finger to anal
contact). It is rarely spread through oral sex. You are at higher risk
of getting HPV if:
- You have had more than one sex partner, or
- Your sex partner(s) has had other partners.
If your health care provider finds you have HPV, your sex
partner(s) should also get checked. They usually will have no
symptoms. For more information about HPV and how to protect
yourself, see the Resources section 2.
Most women with HPV of the cervix do not know they have it.
Most of the time, it does not cause any symptoms. Certain types of
HPV can cause
warts
on the outside of the genitals, but the only
way to know for sure whether you have HPV is by seeing your
health care provider.
Almost all HPV infections clear up on their own. Many women
with HPV will have cell changes at least briefly within a few
months to a year after getting the virus. Most types of HPV do not
lead to cancer. But if HPV does not go away, you are more at risk
of developing a precancerous change that needs to be treated. It is
best to see your health care provider on a regular basis.
|
"I was really afraid
when I found out
I have HPV, but
talking to the nurse
really helped me
understand what it
is and what we can
do about it…"
JESSICA, AGE 28
|
Although HPV itself cannot be treated, the cell changes that it
causes can be treated. Simple treatments that remove or destroy
the cells may prevent cancer. This is why regular pelvic exams and
Pap tests are important, along with care for cell changes.
If you or your partner has HPV, you will share it until your bodies'
immune systems get rid of the infection. If you have sex only with
each other, you will not pass the HPV virus back and forth. This is
because when the HPV goes away, the immune system will
remember that HPV type and keep you from getting it again. Even
though you are protected from one type of HPV, you are not
protected from getting the many other types of HPV.
Finding Abnormal Cells
The Pap test finds certain cell changes before they lead to cancer
or cause you to have symptoms.
These cell changes can almost always be treated so that you don't
get cancer of the cervix. Most changes in the cervix happen
very slowly.
If the lab finds cell changes, the Pap test result is called "positive"
or abnormal. If cells look healthy, the result is called "negative"
or normal.
The Pap test is not always 100-percent accurate. If the test misses
cell changes once, they can often be found the next time you have
one. This is why it is very important that you have regular Pap
tests. You should also go back to your health care provider for care
if you get an abnormal result.
The Pap Test and DES
If you were born between 1940 and 1971, and your mother was
given a synthetic form of the hormone
estrogen
called
diethylstilbestrol (DES)
when she was pregnant with you, be
sure to tell your doctor. Your doctor will want to take additional
cells to check for a rare type of cancer.
|
Almost all cervical cancer begins as an infection with the virus
called HPV. An HPV test, which is done much like a Pap test, can
detect the virus in cervical cells.
Because health care providers know what causes most cervical
cancers, it is important to get an HPV test if your health care
provider recommends one.
In an HPV test, a small number of cells is collected from the
cervix, much like a Pap test. Sometimes this can be done at the
same time as a Pap test. A lab then checks to see if HPV is present.
An HPV test can be useful in cervical cancer
screening in two ways:
- For women of all ages, an HPV test can be useful as
follow-up to a Pap test with an unclear result of ASC-US (see Table 1 1).
- If you are age 30 or older, an HPV test can be very useful if
it is done together with a Pap test as a routine screening for
cancer once every 3 years.
But if you are under age 30, getting an HPV and a Pap test
together on a regular basis is not helpful. HPV tests can lead to
unnecessary treatment, because HPV infection is very common
in women under 30 and usually goes away on its own. This is
why cervical cancer is very rare for women in this age group.
What Do My Pap Test Results Mean?
Your Pap test results could be normal, meaning only normal cells
were found, or abnormal. The term "abnormal" could mean many
different things:
- Your test was unclear
- Your test showed you have an HPV infection
- Your test showed precancer
- Your test showed cancer
See Table 1 1 for more information about what
these results mean and what your health care provider might
recommend you do next. If you have an abnormal result from your
Pap test, it's very important that you get follow-up care and any
needed tests or treatment as suggested by your health care provider.
How you can help improve the chances that
your Pap test results will be correct: |
- Don't have a Pap test when your menstrual period is heavy.
The best time to schedule a Pap test is between 10 and 20
days after the start of your period.
- For about 2 days before a Pap test, do not:
- Douche
- Use any creams or medicine in your vagina unless your
doctor tells you to do so. These may wash away cells or
hide cells with changes.
- Don't have sexual intercourse for 1 or 2 days prior to your
Pap test. This may cause unclear results.
|
|
"My doctor helped
explain what my
Pap test results
meant, and what
I needed to do."
GRETCHEN, AGE 60
|
The Pap test is a very good screening test. But no test is perfect,
including the Pap test. There are a lot of reasons why you might
get an unclear result.
- Not enough cells: The lab sample may not contain enough
cells with changes. This can happen if the area of tissue with
changes is very small or hard to reach. It can also happen if
not enough cells are put on the slide for the lab.
- Cells are clumped together: The lab sample has too many
cells clumped together or hidden by blood or mucus.
Any of these things can make changes hard to spot. Changes that
are missed once are often found the next time. Having another
Pap test can help get a clear result.
Changes in the cervix happen very slowly. So a few months' delay
in getting another test usually does not mean the difference
between getting cancer and not getting cancer.
More serious problems can develop when you do not have regular
Pap tests or when you do not go back to your health care provider
for care after an abnormal result.
Questions To Ask Your Health Care Provider
If you have cervical cell changes, your health care provider may
want to do a series of tests or treatments, or may refer you to
another provider.
- Tests help your health care provider learn more about the
changes in your cervix (see Table 2 3).
- Treatments remove or destroy cells with changes so that
healthy cells can grow back (see Table 4 4).
You should always feel at ease asking your health care provider
about the reason for a test or treatment and what you should
expect during and after it.
|
"When I learned that
my Pap test results were
abnormal, I wondered
just what the doctor
meant by 'abnormal.'"
NANCY, AGE 42
|
Here are some questions you may want to ask:
- What do my test results mean?
- What care is best for me?
- Is this a test designed to help you learn more about the changes
in my cervix? Or is it a treatment to cure the changes?
- What are the possible results? Will I need more care afterward?
- Are there any risks or side effects? How can I manage them?
- Do I need to do anything special to prepare for this test or
treatment?
- Do I need to do anything special to care for myself afterward?
- Will this affect my ability to get or stay pregnant?
- Will my health insurance pay for the treatment you suggested?
If you are concerned about your Pap test results and don't feel right
about your health care provider's recommendations, you may want
to get a second opinion. Changes in the cervix happen very slowly.
Most of the time, they take several years to become cancer. Waiting
a few months before follow-up care usually does not affect the
success of the care you choose. You may want to use this time to:
- Ask your health care provider to have another
pathologist
review your test results.
- Ask another specialist or gynecologist to review your care plan.
(A
gynecologic oncologist, a doctor who specializes in
female cancers, is someone you might want to see.)
Many women feel uncomfortable asking for a second opinion.
They may feel that they are being a bother or that they will offend
their health care provider, but it is very common for women to
seek one. And doctors often expect patients to ask for one.
A second opinion may help you feel more sure that you have
made the best choices about your health.
If you have health insurance, many insurance companies will pay
for a second opinion if you ask for one.
Most of the time, your health care provider will suggest the name
of another specialist if you want a second opinion. You may
choose to visit this second health care provider. Or you may get
names of specialists from your local medical society, a nearby
hospital or medical school, or your friends or family members.
The NCI Cancer Information Service (see Resources 2) can help you
find qualified doctors and programs through cancer centers and
other cancer programs.
Finding the Support You Need
It can be scary when you find out your Pap test is abnormal. Many
women have found it helpful to:
- Ask friends or loved ones for support. They can go to the
health care provider's office with you while you are learning
about choices in testing and treatment.
- Ask your health care provider to:
- Help you understand medical terms that are confusing
- Tell you how other people have handled the types of
feelings that you are having
- Contact the organizations listed in the Resource section 2.
|
"I owed it to myself
and my family to
find out if anything
was wrong. And
once I had the facts,
it was easy to take
the next step."
JENNY, AGE 46
|
Table 1: What Your Pap Test/HPV Test Results Mean and Follow-Up
Possible Result |
What It Means to You |
What Your Health Care Provider May Recommend |
Possible Outcomes |
Normal |
Normal |
Only normal cells were seen on the Pap test. |
Make sure to continue receiving Pap tests at least once every 3
years. |
A False Negative (Looks Normal, But May Not Be)
The Pap test is a very good screening test, but it is not perfect. A single Pap
test may miss up to 20 percent of abnormalities. Changes that are missed once
are usually found the next time. This is why it is important to get a Pap test
at least once every 3 years. |
Abnormal |
Unclear
ASC-US
|
ASC-US (atypical squamous cells-- of undetermined significance)
-
Some cells from the lining of the outer cervix (also called squamous cells) do
not appear normal.
-
The health care provider will need to do additional tests to clarify the
results.
|
-
Follow up with repeat Pap tests every 4-6 months.
-
HPV testing
-
Immediate
colposcopy (a test that can be done
in the doctor's office to get a magnified view of your cervix)
|
Abnormal Pap Test Result
If a repeat Pap test is abnormal, your health care provider will probably
recommend a colposcopy.
Positive HPV Test Result
If your HPV test is positive, your health care provider will probably recommend
a colposcopy.
Negative HPV Test Result
If your HPV test is negative, your health care provider may recommend a repeat
screening in 1 year.
Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy,
endocervical curettage, or both.
|
Abnormal |
Unclear
ASC-H
AGC
|
ASC-H (atypical squamous cells-- cannot exclude HSIL)
-
Cervical cells do not appear normal.
-
A high-grade lesion may be present, but the cell changes are too minor to be
sure.
AGC (atypical glandular cells)
-
Some glandular cells in the lining of your cervix appear abnormal.
|
Colposcopy |
Normal Colposcopy Result
If cervical tissue looks healthy, your health
care provider may not need to do any further testing or treatment right away,
but may recommend a repeat Pap test or HPV test in 6-12 months.
Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy,
endocervical curettage, or both.
|
Abnormal |
LSIL
|
LSIL (low-grade squamous intraepithelial lesion)
-
Squamous cells are abnormal, but are usually not precancerous.
|
Colposcopy |
Normal Colposcopy Result
If cervical tissue looks healthy, your health care provider may not need to do
any further testing or treatment right away, but may recommend a repeat Pap
test or HPV test in 6-12 months.
Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider may do a biopsy,
endocervical curettage, or both.
|
Abnormal |
Precancer
HSIL
AIS
|
If you have one of the results below, it is very important that you
get the necessary tests and treatments.
HSIL (high-grade squamous intraepithelial lesion)
-
The lesion is precancerous; without treatment, it may turn into invasive
cancer.
AIS (adenocarcinoma in situ)
-
A precancerous lesion is found in the glandular tissue of the cervix.
|
Colposcopy |
Normal Colposcopy Result
If cervical tissue looks healthy, your health care provider may still need to
do further testing or treatment.
Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider will probably do a
biopsy, endocervical curettage, or both.
|
Abnormal |
Cancer |
Cancer cells are present in the cervix. |
Colposcopy
Your health care provider will probably refer you to a gynecologic oncologist.
|
Abnormal Colposcopy Result
If your colposcopy is abnormal, your health care provider will probably do a
biopsy, endocervical curettage, or both.
|
This table is based on the American Society for Colposcopy and Cervical
Pathology (ASCCP) consensus guidelines.
For more information on cells of the cervix, see the
What is the Cervix 5 in this booklet.
Table 2: Tests or Follow-Up Treatments That Health Care Providers Use for Abnormal Pap Tests
Possible
Test or
Treatment |
What It Is |
What To Expect |
What Your Health
Care Provider May
Recommend |
Repeat Pap
test |
- Same procedure as the first Pap test
- Done if you have minor cell changes
|
Same procedure as the first Pap test |
You may need to return
for repeat Pap tests every
4-6 months until you
have two normal results
in a row.
After two normal results
in a row, you can go
back to having Pap tests
at least once every 3
years. |
HPV testing |
- A sample of cells from your cervix is tested in the
lab. This looks for HPV
DNA
in the cells.
|
Similar to a Pap test |
If the test shows that
you have HPV, your
health care provider may
recommend a
colposcopy. |
Hormone
therapy |
- An estrogen cream applied to your vagina/cervix for
a few weeks
- Prescribed by your doctor if you have ASC-US and
are near or past menopause
|
Cell changes caused by low hormone
levels will go away, and changes that are due
to lesions will remain. |
A repeat Pap test is done
after 6-8 weeks.
If the results of the
repeat Pap test are
abnormal again, your
health care provider may
recommend a
colposcopy. |
Colposcopy |
- The most common test for women who get an
abnormal Pap test result
- Your health care provider uses a special tool called a
colposcope
to view your cervix from outside the
body. The colposcope has a bright light with a
magnifying lens.
|
Can be done in your health care provider's
office in about 15 minutes
Your health care provider:
- Puts a speculum into your vagina to see
your cervix
- Applies diluted white vinegar to the surface
of your cervix
Areas that are abnormal turn white from the
vinegar and can be seen more easily.
You may feel nothing at all or a mild tingling.
|
Depending on the
results, your health
care provider may
recommend further tests
or treatments. |
Colposcopy
with biopsy
and/or
endocervical
curettage |
- Done if the colposcopy found any abnormal tissue
in your cervix (see previous page)
- For the biopsy, your health care provider will
remove a small piece of tissue from the abnormal
area. This specimen is sent to a lab for study.
- For the endocervical curettage, your health care
provider removes cells from inside your endocervical
canal with a small spoon-shaped tool called a
curette; this takes about 10 seconds. This specimen
is sent to a lab for study.
|
May cause mild pain and cramping (much like
menstrual cramps)
You may have less pain and cramping if you
take ibuprofen (brand names include Advil®,
Motrin®, and Nuprin®) about an hour before
the test.
You may have a brown discharge from your
vagina for a few days afterward; you may want
to wear a pad.
It takes several days for your cervix to heal. To
help prevent infection and bleeding during this
time:
- Do not use tampons.
- Do not douche.
- Do not do any heavy lifting.
- Do not have sex.
|
Depending on the
results, your health
care provider may
recommend further tests
and/or treatments. |
|
Table 3: What Does It Mean: Results From Your Biopsy or Endocervical Curettage
Possible Result |
What Your Health Care Provider May Recommend |
Tissue appears normal |
If cervical tissue appears normal, your health care provider may not need
to do any further testing or treatment right away, but may recommend a
repeat Pap test or HPV test in 6-12 months. |
Tissue shows only mild changes (low-grade) |
Biopsy may have removed all abnormal tissue.
You may or may not need more treatment--even if some abnormal tissue
remains.
Your health care provider may not need to do any further testing or
treatment right away, but may recommend a repeat Pap test or HPV test
in 6-12 months. |
Results are unclear |
Your doctor may do more tests, such as
conization. |
Severe (high-grade) changes are found |
You will need treatment to remove more tissue.
Your doctor may perform
LEEP,
cryotherapy,
laser therapy, or
conization. |
Invasive cancer cells are found |
Your doctor will do more tests to find out the
stage
(extent) of the
cancer. Your treatment will depend on:
- The stage of your cancer
- Your age
- Whether you may want to become pregnant
- Your general health
- Other factors
|
To learn about more treatment options, see the National Cancer Institute booklet,
"What You Need To Know About Cancer of the Cervix 6," or visit www.cancer.gov and
search for "cervical cancer."
Table 4: Treatments for Major Cell Changes
Treatment |
What It Is |
What To Expect |
What You Should Do |
LEEP |
LEEP (loop electrosurgical excision procedure)
-
A procedure that uses an electrical current passed through a thin wire loop to
cut away tissue
-
Provides a tissue sample for the lab to study
|
This procedure is usually done in your doctor's office and takes
only a few minutes.
During
Your doctor will:
-
Put a speculum into your vagina to view the cervix
-
Numb your cervix using a small needle
-
Begin the LEEP when the cervix is numb
After
-
It takes several weeks for the tissue to heal and grow back.
-
You may have mild bleeding and a discharge for several weeks.
|
Before
You may have less pain and cramping if you take ibuprofen (brand names include
Advil ®, Motrin®, and Nuprin®) about an hour before the test.
After
It takes several weeks for your cervix to heal. To help prevent infection and
bleeding during this time:
-
Do not use tampons.
-
Do not douche.
-
Do not do any heavy lifting.
-
Do not have sex.
|
Cryotherapy |
-
A procedure that uses a special cold probe to freeze abnormal tissue
-
The tip of the probe freezes to the cervix and stays attached while a round
piece of tissue is destroyed.
|
This procedure is usually done in the doctor's office and only
takes a few minutes.
During
Your doctor will:
-
Put a speculum into your vagina to view the cervix
-
Insert a special cold probe for about 3 minutes to freeze a controlled amount
of tissue
-
Warm the probe after the tissue has been destroyed and remove it from the
cervix
After
-
It takes several weeks for your cervix to heal.
-
You may have a watery, brownish discharge for several weeks.
|
Before
You may have less pain and cramping if you take ibuprofen (brand names include
Advil®, Motrin®, and Nuprin®) about an hour before the test.
After
It takes several weeks for your cervix to heal. To help prevent infection and
bleeding during this time:
-
Do not use tampons.
-
Do not douche.
-
Do not do any heavy lifting.
-
Do not have sex.
|
Conization |
-
Uses a knife or laser to remove a cone-shaped piece of tissue, located higher
up in the cervical canal
-
The amount of tissue removed depends on the size of the lesion
|
This procedure is usually done in a hospital.
Before
Your doctor will give you anesthesia before performing the operation.
After
-
Stitches are often needed to close the wound.
-
Bleeding may occur.
-
It takes several weeks for your cervix to heal.
|
Before
You may have less pain and cramping if you take acetaminophen (brand names
include Tylenol® and Anacin-3®) about an hour before the test.
After
It takes several weeks for your cervix to heal. To help prevent infection and
bleeding during this time:
-
Do not use tampons.
-
Do not douche.
-
Do not do any heavy lifting.
-
Do not have sex.
|
Hysterectomy |
-
Surgical removal of the uterus
|
-
This surgery is done in the hospital and usually requires an overnight stay.
-
Your doctor will give you an epidural or anesthesia before performing the
surgery.
-
The doctor removes your uterus either through a surgical incision (cut) in your
abdomen or through your vagina.
-
You will not be able to become pregnant after having this surgery.
|
This is major surgery.
You should discuss follow-up care with your doctor.
|
|
Resources
You may want more information for yourself, your family, and your
health care provider. The following services are there to help you.
Cancer Information Service
Gives up-to-date information on cancer to patients and their
families, health professionals, and the general public. Information
specialists explain scientific information in plain language and
respond in English or Spanish.
www.cancer.gov
The National Cancer Institute's Web site contains information
about cancer causes and prevention, screening and diagnosis,
treatment, symptom management, and survivorship; clinical trials;
statistics, funding, and training; and NCI's programs and research
activities.
Toll-free: | 1-800-MEDICARE (1-800-633-4227) |
TTY: | 1-877-486-2048 |
Web site:
|
www.medicare.gov
|
Medicare helps pay for screening Pap tests every 2 years. Medicare
may pay more often if necessary.
NWHIC provides a gateway to women's health information.
NWHIC is sponsored by the U.S. Department of Health and
Human Services Office on Women's Health.
U.S. Centers for Disease Control and
Prevention--CDC INFO
Toll-free and En Español: | 1-800-CDC-INFO (1-800-232-4636) |
TTY: | 1-888-232-6348 |
CDC-INFO is available 24 hours a day, 7 days a week, 365 days a year for STD information
and referrals to STD clinics.
American Social Health Association (ASHA)
National HPV and Cervical Cancer Prevention
Resource Center
A free information packet about HPV is available from the tollfree
number above. The Resource Center also provides online
resources and information about HPV on their Web site.
Planned Parenthood Federation of America
For medical questions or to schedule an appointment, call
the toll-free number listed above. Information about HPV
and cervical cancer can be found at:
www.plannedparenthood.org/sti/HPVfacts1.html.
|
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